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Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Instructions | Page 1 of 3
670 Hawthorne Avenue, SE tel. 503.362.2666
Suite 220 email: osbeels@osbeels.org
Salem, Oregon 97301 Web: oregon.gov/osbeels
Professional Engineers/Land Surveyors/Photogrammetrists (PE/PLS/RPP)
Instructions for Filling Out the
Application for Registration by Examination & Related Forms
The following instructions are provided to assist in
completing the application. PLEASE NOTE: It is the applicant’s responsibility
to compile and submit all documentation required.
PLEASE READ the applicable Oregon Revised Statutes Failure to properly fill out and complete the
(ORSs) and the Oregon Administrative Rules (OARs). To application forms may result in determining
locate the ORSs and the OARs, visit our Web site at ineligibility for a professional examination.
www.oregon.gov/osbeels. Click on the “Revised Statutes”
link for the ORSs. Click on the “Administrative Rules” for
the OARs.
It is the Applicant’s responsibility to review these requirements prior to making application to the Board.
Who Should Fill Out the PE/PLS/RPP Application?
Individuals who want to apply for a Professional Engineering (PE) or Professional Land Surveying
(PLS) or Professional Photogrammetrist (RPP) registration by examination.
Examinations Offered
There are different examinations offered in the Spring and Fall.
National Council of Examiners for Engineering and Surveying (NCEES) Examinations:
Spring Examinations Fall Examinations
Chemical Naval Architecture & Marine Agricultural Industrial
Civil Engineering Chemical Mechanical
Electrical & Computer Mechanical Civil Metallurgical
Environmental Structural (16-hour) Control Systems Nuclear
Land Surveying (6-hour) Electrical & Computer Structural (16-hour)
Environmental Land Surveying (6-hour)
Fire Protection
Oregon Specific Examinations:
Spring Examinations Fall Examinations
Forest Photogrammetric Mapping Acoustical Oregon Specific Land
Oregon Specific Land California (CA) Geotechnical Surveying
Surveying
See the following OAR for detailed information: OAR 820-010-0440.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-INST, updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Instructions | Page 2 of 3
Reasonable Accommodations
National Examinations — See the NCEES Web site for more information at www.ncees.org.
Oregon Specific Examinations — Reasonable accommodations may be provided for applicants who have documented
disabilities within the meaning of the American Disabilities (ADA) Act of 1990 or for applicants whose religious
convinctions prohibit them from testing on the scheduled examination date.
See the following OAR for detailed information: OAR 820-010-0443.
Deadlines
Which Examination Package must be postmarked by 5:00 p.m. Last day to withdraw and forward:
Administration? on:
Spring December 1st March 1st
Fall June 1st September 1st
Applications must be postmarked or hand delivered by 5:00 p.m. on the 1st day of December for the Spring examination
administration or by 5:00 p.m. on the 1st day of June for the Fall examination administration. When this deadline falls on
a Saturday, Sunday, or legal Holiday applications are accepted until 5:00 p.m. on the preceding business day.
Regardless of whether written correspondence from OSBEELS is received concerning the application status, to
postpone an examination to the next examination, you must notify OSBEELS in writing by March 1st for the Spring
examinations and by September 1st for the Fall examinations. Once OSBEELS processes the request, acknowledgement
will be sent to the applicant regarding the status of the request. OSBEELS will not forward an examination more than
once. Any requests received after the above stated dates will not be processed and fees will be forfeited.
See the following OARs for detailed information: OAR 820-010-0300 and OAR 820-010-0442.
Application Fees
The application fees are located in OAR 820-010-0305. Application fees are non-refundable. Applicants will be notified by
OSBEELS of eligibility for entrance to the examination. In addition, OSBEELS will continue to maintain and store records
pursuant to the Oregon Administrative Rules Chapter 166, Division 350.
See the following OARs for detailed information: OAR 820-010-0300, OAR 820-010-0305, and OAR 820-010-0442.
Registering for An Examination
National Examinations — Once approval is received from OSBEELS, applicants are required to register for admittance to
the examination with NCEES. Please visit their Web site at www.ncees.org.
Oregon Specific Examinations — Once approval is received from OSBEELS, no further action is required. Approximately
three weeks prior to the examination, OSBEELS will mail admittance packets to applicants approved to sit for an Oregon
specific examination. If this information has not been received within this timeframe, please contact us.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-INST, updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Instructions | Page 3 of 3
Additional General Examination Information
National Examinations — Study materials and details concerning the NCEES examinations are available on the NCEES
Web site at www.ncees.org.
Oregon Specific Examinations — Study materials and details concerning the Oregon Specific examinations are available
on the OSBEELS Web site at www.oregon.gov/osbeels.
About the Principles and Practice of Engineering (PE) Examination
See the following OAR for detailed information: OAR 820-010-0415.
About the Principles and Practice of Geotechnical Engineering (GE) Examination
See the following OAR for detailed information: OAR 820-010-0400.
About the Principles and Practice of Structural Engineering (SE) Examination
See the following OAR for detailed information: OAR 820-010-0417.
About the Principles and Practice of Land Surveying (PLS) Examination
See the following OAR for detailed information: OAR 820-010-0425.
About the Oregon Specific Land Surveying Examination
See the following OAR for detailed information: OAR 820-010-0425.
About the Photogrammetric Mapping Examination
See the following OAR for detailed information: OAR 820-010-0427.
How Applications are Processed
Applications will be processed according to the date received by the OSBEELS office.
GENERAL INSTRUCTIONS
Step 1: Complete the Application form.
Step 2: Gather completed forms and documents and put together in a single package (see OAR 820-010-0215) for
mailing.
Step 3: Send package, including application payment to the Oregon State Board of Examiners for Engineering and Land
Surveying (OSBEELS):
OSBEELS
670 Hawthorne Avenue, SE
Suite 220
Salem, OR 97301
Step 4: If correspondence has not been received from the OSBEELS within 60 days of submittal, please contact us.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-INST, updated 08/05/2011 email: osbeels@osbeels.org
Office Use Only - Date Received: Office Use Only -
Date Paid:
BOARD OF EXAMINERS
FOR ENGINEERING &
LAND SURVEYING
670 Hawthorne Avenue, SE tel. 503.362.2666
Suite 220 email: osbeels@osbeels.org
Salem, Oregon 97301 Web: oregon.gov/osbeels
Office Use Only - ID #
A
Professional Engineers/Land Surveyors/Photogrammetrists
Application for Registration by Examination
A: Applicant Contact Inform a t i o n
Applicant Contact Information
First name (personal name) Middle name or initial Last name (family name)
Name as you want it to appear on your wall certificate
If you have a Social Security number Oregon law requires that it be used. Only use a Passport number if you don’t have a
Social Security number.
o Social Security # OR o Passport # Country issuing passport
Birth date (Mo/Day/Yr) Where do you want correspondence mailed to?
o Home address OR o Business address
Home address (include any apartment number) Home/Personal phone #
City State or Province Zip/Postal code Home email address
Business name Business phone # Business fax #
Business address (include any suite number)
City State or Province Zip/Postal code Business email address
Professional Engineers/Land Surveyors/Photogrammetrists
B
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Application | Page 2 of 7
Select examination, date, and branch (if applicable)
B: E x a m i n a t i o n & Pa y m e n t
o Professional Engineering Examination See OAR 820-010-0440 for the Schedule of Examinations.
Select examination schedule (choose only one)
o Spring Examination o Fall Examination
Select branch (you must choose one)
o Acoustical o Control Systems o Industrial
o Agricultural o Electrical & Computer o Mechanical
o CA Geotechnical o Environmental o Metallurgical and Materials
o Chemical o Fire Protection o Naval Architecture & Marine Engineering
o Civil o Forest o Nuclear
o Structural Engineering Examination(s)
Select examination schedule for each of the following examinations
o Spring Examination o Fall Examination Both; Structural 16-hour
o Professional Land Surveying Examination(s)
Select examination schedule for each of the following examinations
o Spring Examination o Fall Examination Both; NCEES Principles and Practices of Land Surveying
and Oregon Specific Land Surveying
o Professional Photogrammetric Mapping Examination
Select payment method (choose one)
o Check or Money Order (payable to the o Cash Amount Enclosed:
OSBEELS)
o Debit or Credit Card (Visa, Mastercard, Discover, or AmEx) Total Charge to Card:
Card Number Exp. Date Security Code* Billing Zip/Postal Code
Signature (serves as payment authorization if paying by debit or credit card) Signature Date (Mo/Day/Yr)
* Debit or Credit Card Security Codes
If submitting a payment to OSBEELS for fees by debit or credit card, please provide the security code. These codes are a security feature that
appears on the back of most Visa, MasterCard, and Discover cards, and on the front of American Express cards. This code is a three or four-digit
number which provides a cryptographic check on the information embossed on the card.
American Express Card Users: Look for the 4-digit code printed on the front of the card just above and to the right of the main card number.
This 4-digit code is the card security code. Visa, MasterCard, and Discover Card Users: Flip the card over and look at the signature box. A
special 3-digit code will be located in the signature box. This 3-digit code is the card security code.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-APP updated 08/05/2011
, email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
C
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Application | Page 3 of 7
C: General Questions
Answer the following questions:
Have you ever had any criminal convictions relating to the profession for which you are applying? o Yes o No
Has your professional registration ever been denied, revoked, suspended, surrendered, stipulated,
on probation, or been subject to any restriction or disciplinary action in any jurisdiction?
o Yes o No
Have you ever been found guilty of misconduct, dishonesty, fraud, incompetence, negligence,
and/or gross negligence in the practice of engineering, land surveying, and/or photogrammetric o Yes o No
mapping?
If the answer is “yes” to any of the above stated questions, please submit a written explanation on Form C-ADD with
your application.
Are you a citizen of the United States? o Yes o No
D
All information provided with your response may be considered public information unless required to be kept confidential by state or
federal law.
o I’ve attached form C-ADD
D : Education Summary
Summarize your education:
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
o I’ve attached form D-ADD listing additional Universities/Institutions
To go along with Section D: Education Summary you will also need to provide:
o Official Transcripts from each University/Institution listed
For each University/Institution listed above and on Form D-ADD you must request an official transcript. These transcripts must be
kept in the original and unopened envelopes from the Registrar’s office and must be included in the application package when it is
submitted to OSBEELS. OSBEELS will not accept photocopies and/or opened transcripts.
See the following OARs for detailed information: OAR 820-010-0225, OAR 820-010-0226, OAR 820-010-0227, OAR 820-010-0228, OAR
820-010-0230, OAR 820-010-0231, and OAR 820-010-0236.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-APP updated 08/05/2011
, email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
E
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Application | Page 4 of 7
E : Ve r i f i c a t i o n S u m m a r y
Summarize EI/LSI Examination and Certification
State Issued Certification Certification Number Issue Date (Mo/Day/Yr)
State Issued Certification Certification Number Issue Date (Mo/Day/Yr)
To go along with Section E: Verification Summary you must also have a Licensing Authority complete a Verification.
o Form E-1: Verification Request
If the Fundamentals of Engineering and/or Land Surveying examination was successfully completed in the State of
Oregon, Form E-1: Verification Request is not necessary.
See the following ORSs and OARs for detailed information: ORS 672.102, ORS 672.115, OAR 820-010-0230, OAR 820-010-0231, and OAR
820-010-0236.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-APP updated 08/05/2011
, email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
F
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Application | Page 5 of 7
F: Reference Summary
Summarize your references; provide a minimum of five names, and at least three must be registered professionals
Reference #1. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Reference #2. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Reference #3. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Reference #4. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Reference #5. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
o I’ve attached form F-ADD listing additional references
To go along with Section F: Reference Summary you must also complete and have others complete:
o Form F-1: Reference Details
Have each reference listed above (and on Form F-ADD) complete a copy of Form F-1: Reference Details.
Qualifying experience accrued must be included in the application, and all qualifying experience must be certified as meeting the
definition of engineering technician, land surveying technician, or photogrammetric mapping technician work, and/or engineering,
land surveying, or photogrammetric mapping work by the registrant who supervised the work.
See the following OARs for detailed information: OAR 820-010-0010 and OAR 820-010-0255.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-APP updated 08/05/2011
, email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Application | Page 6 of 7
G
G: Experience Summary
List your experience in date order, beginning with your most Work Time in Years and Months
recent or current position. Time is calculated in years and (for example, 2 years 0 months, 3 years 11 months)
months up to the examination date. performing engineering performing engineering,
technician, land surveying land surveying, or
technician, or photogrammetric photogrammetric mapping
mapping technician work work
Employer/Company #1 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
Employer/Company #2 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
Employer/Company #3 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
Employer/Company #4 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
Employer/Company #5 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
# Years AND # Months # Years AND # Months
Total from Form G-ADD (if applicable):
Grand Total of All Experience Listed:
o I’ve attached form G-ADD listing additional experience
To go along with Section G: Experience Summary you must also complete:
o Form G-1: Experience Details
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-APP updated 08/05/2011
, email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
H
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
Application | Page 7 of 7
As part of your application for an initial or renewed occupational, professional or recreational license, certification, or
H: Soc i a l S e c u r i t y G u i d e l i n e s
registration issued by OSBEELS, you are required to provide your Social Security Number to OSBEELS. This is mandatory.
The authority for this requirement is ORS 25.785, ORS 305.385,42 USC § 405 (c) (2) (C) (I), and 42 USC § 666 (a) (13). Failure to
provide your Social Security Number will be a basis to refuse to issue or renew the license, certification, or registration you
seek. This record of your Social Security Number will be used for child support enforcement and tax administration purposes
(including identification) only, unless you authorize other uses of the number. Although a number other than your Social
Security Number appears on the face of the licenses, certificates, or registrations issued by OSBEELS, your Social Security
Number will remain on file with OSBEELS.
If, the United States Social Security Administration has not issued you a social security number, you must follow these
guidelines:
a. form must be signed by you;
b. you are attesting to the fact that no social security number has been issued to you by the United States Social
Security Administration; and
c. are acknowledging that knowingly supplying false information under this section is a Class A misdemeanor,
punishable by imprisonment of up to one year and a fine of up to $6,250.
By providing the following signature, you are agreeing to comply with the guidelines listed above
I
Signature Date (Mo/Day/Yr)
I : A p pli cant Signature
I hereby certify under penalty of perjury that the information provided on this application and all
appended sheets is true and correct. I am the applicant named in this application, I have read the contents
thereof and, to the best of my knowledge and belief, the foregoing statements are true and correct in every
respect.
Signature Date (Mo/Day/Yr)
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-APP updated 08/05/2011
, email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING
C-ADD: Explanation | Page 1 of 1
Professional Engineers/Land Surveyors/Photogrammetrists
C-ADD: Explanation
for Section C, General Questions
C-ADD
Applicant Name
C-ADD: Explan a t i o n
Please provide an explanation for your answers to Section C: General Questions on the Application. If you need more than
one page, you can reprint or copy this page.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-C-ADD updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING D-ADD: Additional Universities/Institutions | Page 1 of 1
Professional Engineers/Land Surveyors/Photogrammetrists
D-ADD: Additional Universities/Institutions Addendum
for Section D, Education Summary
D-ADD
Applicant Name
D -A DD: Additional Universities/Instit u t i o n s
Summarize your education
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
Name of University/Institution Attended (Mo/Yr to Mo/Yr) Graduation Date Degree Received
For each University/Institution listed above you must request an official transcript. These transcripts must be kept
in the original and unopened envelopes from the Registrar’s office and must be included in the package when it is
submitted to OSBEELS. OSBEELS will not accept photocopies and/or opened transcripts.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-D-ADD, updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING E-1: Verification Request | Page 1 of 2
Professional Engineers/Land Surveyors/Photogrammetrists
E-1: Verification Request
for Section E, Verification Summary
Complete the Applicant Information section and submit
to the state board for completion. The Verification Request Note that some states may require a fee for this service.
form may be included in the package in the original and
If the Fundamentals of Engineering or Land Surveying (FE/
unopened envelope. However, some states may require
FLS) examination was taken in the State of Oregon, you do
direct submission to OSBEELS. not need to complete or send this form, but must complete
E-1
the Verification Summary on page 4 of the Application form.
Contact Information:
E-1: Applicant Information
Applicant Name
Home/personal phone # Fax # Business phone #
Mailing Address (include any apartment number)
City State or Province Zip/Postal code Country
INSTRUCTIONS FOR STATE SECTION
Please complete the following items and return this entire form to the applicant in a sealed envelope. Please
place an official seal on the last page. If the state does not allow for this method, please return this form to OS-
BEELS at 670 Hawthorne Avenue, SE, Suite 220, Salem, OR 97301.
C e rt i fi c at i on I nf orm at i on
Applicant registered as: Certificate # Issue Date (Mo/Day/Yr) Expiration Date
(Mo/Day/Yr)
Engineering Intern
Land Surveying Intern
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-E1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING E-1: Verification Request | Page 2 of 2
Written Examination
Written examination details
Hours NCEES Exam Exam Date
(Yes/No) (Mo/Day/Yr)
FE
FLS
Disciplinary Information
Answer the following questions:
Has any disciplinary action ever been taken against the applicant? o Yes o No
If so, has this disciplinary case been satisfied to the state’s requirements? o Yes o No
Details and/or Remarks:
Your signature Place Official Seal
Your Title:
State:
Date
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-E1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING F-1: Reference Details | Page 1 of 5
Professional Engineers/Land Surveyors/Photogrammetrists
F-1: Reference Details for Reference #____
for Section F, Reference Summary
Complete one copy for each reference. Fill out the Applicant
References need to have knowledge of your engineering
Information section before delivering it to the reference for
technician, land surveying technician, or photogrammetric
completion. Make sure the number used for their summary
mapping technician work (if applicable) and engineer-
information in Section F of the Application form or on form ing, land surveying, or photogrammetric work. Provide a
F-ADD matches the number you write in the space above.
F-1
minimum of five references; at least three must be registered
When the reference returns this form to you put the original, professionals. For information regarding references, please
unopened, and signed envelope in the package for OSBEELS. refer to OAR 820-010-0255.
Applicant Contact Information:
F-1: Applicant Information
Applicant name
Home/personal phone # Fax # Business phone #
Where reference should mail completed form (include any apartment number)
City State or Province Zip/Postal code Country
Applying for: o Initial Professional Engineering Examination
o Initial Professional Land Surveying Examination
o Initial Professional Photogrammetry Examination
Discipline of Engineering (i.e.
civil, mechanical, electrical):
Type of Employment Start date (Mo/Yr) End date (Mo/Yr)
o Full time o Part time
Name of Employer/Company Address Phone #
Applicant’s position Reference’s position
Applicant’s duties and responsibilities
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-F1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING F-1: Reference Details | Page 2 of 5
INSTRUCTIONS FOR REFERENCE
Your name appears as a reference that can attest to the applicant’s ability and professional experience as a professional
engineer, professional land surveyor, or professional photogrammetrist (as indicated in applicant section). In addition to
the written record completed by the applicant, OSBEELS needs the testimony of those who can, from personal knowledge,
attest to the competency of the applicant in the field of practice for which the applicant has applied. Thus, OSBEELS
respectfully requests your assistance in fulfilling its responsibility to the extent of asking you to answer all the questions
on this form.
Please complete the following sections and return this entire form to the applicant in a sealed envelope. Please sign
your name across the sealed edge on the return envelope.
Reference Information
Reference Informatio n
Reference name Home/Personal phone #
State of current registration PE/PLS/RPP # Issue date Expiration/Renewal date
Field of practice Name of current Employer/Company
Position in Employer/Company Employer/Company phone #
Employer/Company fax # Email address
Employer/Company address
City State or Province Zip/Postal code Country
Kind of business
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-F1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING F-1: Reference Details | Page 3 of 5
Is the information stated by the applicant (on page 1 of this form) correct as stated?
Reference Information
o Yes o No o I do not have adequate knowledge to reply
If NO, please explain: (In particular, note the stated time periods, duties, responsibilities, and relationship of the applicant to
you.)
Indicate when you had knowledge of the applicant’s engineering technician, land surveying technician, or photogrammetric
mapping technician work, and/or engineering, land surveying, or photogrammetric work
Start date (Mo/Yr) End date (Mo/Yr)
Comments
Did you supervise the applicant’s work?
o Yes o No o I do not have adequate knowledge to reply
Supervised from (Mo/Yr) Supervised to (Mo/Yr)
If YES, please explain:
From your personal knowledge indicate your appraisal of the applicant’s potential to practice engineering, land surveying, or
photogrammetry by placing an “X” in the appropriate boxes below. If “unsatisfactory” box is checked, please explain in the
comments box.
SATISFACTORY UNSATISFACTORY UNKNOWN
Technical Competence o o o
Professional Integrity o o o
Professional Judgement o o o
Comments
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-F1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING F-1: Reference Details | Page 4 of 5
Answer the following questions:
Does the applicant’s work meet the definitions as indicated in the ORS 672.005, ORS 672.020, ORS 672.025,
ORS 672.028, and OAR 820-010-0010?
o Yes o No
If NO, please explain:
If registered as an engineer, land surveyor, or photogrammetrist would you employ the applicant in a
position of trust?
o Yes o No
If NO, please explain:
Please review the ORS 672.045, the ORS 672.200, and the rules of Professional Conduct in Division 20 of
the Oregon Administrative Rule (OAR) Chapter 820. Do you have reason to believe that the applicant has o Yes o No
violated any of these standards?
If YES, please explain:
Do you have any reservations concerning this applicant? o Yes o No
If YES, please explain:
Do you recommend that we check further? o Yes o No
If YES, please explain:
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-F1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING F-1: Reference Details | Page 5 of 5
Additional Remarks. OSBEELS requests that you comment on information regarding the applicant’s engineering technician,
land surveying technician, or photogrammetric mapping technician work (if applicable), and/or engineering, land surveying,
or photogrammetric mapping experience, and estimate their potential in the practice of engineering, land surveying, or
photogrammetry. Please direct your remarks to the field of practice applied for in the section filled out by the applicant.
Note: You are responsible for the information you provide as a professional.
Your signature Place Professional Seal below (if applicable)
Date
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-F1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING F-ADD: Additional References | Page 1 of 1
Professional Engineers/Land Surveyors/Photogrammetrists
F-ADD: Additional References Addendum
for Section F, Reference Summary
F-ADD
Applicant Name
F-ADD: Additional Ref e r e n c e s
Summarize your additional references
Reference #6. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Reference #7. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Reference #8. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Reference #9. Name Daytime Telephone Occupation
Mailing Address Registration No. State of Registration
Have each reference listed above complete a copy of Form F-1: Reference Details.
Qualifying experience accrued must be included in the application, and all qualifying experience must be certified as meeting the defi-
nition of engineering technician, land surveying technician, or photogrammetric mapping technician work, and/or engineering, land
surveying, or photogrammetric mapping work by the registrant who supervised the work.
See the following OARs for detailed information: OAR 820-010-0010 and OAR 820-010-0255.
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-F-ADD, updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING G-1: Experience Details | Page 1 of 1
Professional Engineers/Land Surveyors/Photogrammetrists
G-1: Experience Details for Company #____
for Section G, Experience Summary
Applicant Name
G-1
Complete one copy for each Employer/Company listed in Section G and on Form G-ADD. Make sure the company
number used for the Employer/Company’s summary information in Section G of the Application form or on form
G-ADD matches the number you write in the space above, and that the Employer/Company name, start date, and end
date fields match.
Employer/Company name Start date (Mo/Yr) End date (Mo/Yr)
G-1: Experience Details
Reference name
Describe character of work including specific engineering technician, land surveying technician, or
photogrammetric mapping technician (if applicable), and/or engineering, land surveying, or photogrammetric
mapping duties and extent of responsibilities
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-G1 updated 08/05/2011 email: osbeels@osbeels.org
Professional Engineers/Land Surveyors/Photogrammetrists
BOARD OF EXAMINERS Registration by Examination
FOR ENGINEERING &
LAND SURVEYING G-ADD: Additional Experience | Page 1 of 1
Professional Engineers/Land Surveyors/Photogrammetrists
G-ADD: Additional Experience
for Section G, Experience Summary
Applicant Name
G-ADD: Additional Exp e r i e n c e
List your experience in date order, beginning with your Work Time in Years and Months
current or most recent position.Time is calculated in years (for example, 2 years 0 months, 3 years 11 months)
and months up to the examination date. performing engineering performing engineering,
G-ADD
technician, land surveying land surveying, or
technician, or photogrammetric photogrammetric mapping
mapping technician work work
Employer/Company #6 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
Employer/Company #7 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
Employer/Company #8 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
Employer/Company #9 name Start Date (Mo/Yr) # Years AND # Months # Years AND # Months
Positions Held End Date (Mo/Yr)
# Years AND # Months # Years AND # Months
Total (transfer total to page 6 of the application form)
To go along with Section G: Experience Summary and Form G-ADD you must also complete:
o Form G-1: Experience Details
Oregon State Board of Examiners for Engineering and Land Surveying tel. 503.362.2666
form PEPLS-G-ADD, updated 08/05/2011 email: osbeels@osbeels.org
